med surg I-Chapter 23: Management of Patients With Chest and Lower Respiratory Tract Disorders

You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

Pain in the calf

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

encourage increased fluid intake

A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following?

pleaural effusion

A client presents to the ED reporting dyspnea on exertion and overall weakness. The client's pulmonary arterial pressure is 40/15 mm Hg. These symptoms indicate that the client may have which condition?

pulmonary arterial hypertension P: 599

what is secondary/ acquired resistance?

resistance to one or more antituberculotic agents in patients undergoing therapy.

what is multidrug resistance

resistance to two agents, isoniazid (INH) and rifampin. Tertiary drug resistance is not a type of resistance.

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:

significant explanation: An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.

The nurse is planning the care for a patient at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? (Select all that apply.)

- Encouraging a liberal fluid intake -Assisting the patient to do leg elevations above the level of the heart -Using elastic stockings, especially when decreased mobility would promote venous stasis - Applying a sequential compression device

The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?

6-12 mo

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

A positive reaction indicates that the client has been exposed to the disease.

A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema?

Encourage breathing exercises. explanation: The nurse should institute droplet precautions, isolate suspected and confirmed influenza patients in private rooms, or place suspected and confirmed patients together, and not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypercapnia, hypoventilation, and hypoxemia Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation. P: 584

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?

Using strict hand hygiene

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?

acute respiratory distress syndrome explanation:Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C, and D are incorrect.

what is a pneumothorax

air in the pleural space

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

aspiration pneumonia explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client?

deficient knowledge of the disease process explanation: This client is exhibiting Deficient knowledge about the disease process and treatment regimen; treatment of tuberculosis no longer requires isolation, provided the client complies with the ordered medication regimen. Although the client is upset, his question reflects sadness at the prospect of being separated from his family rather than anxiety about the disease. Because he has just been diagnosed and hasn't had a chance to demonstrate compliance, a nursing diagnosis of Social isolation isn't appropriate. A diagnosis of Impaired social interaction usually has a psychiatric or neurologic basis, not a respiratory one, such as pulmonary tuberculosis.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

dyspnea/ wheezing P: 577

Which of the following interventions does a nurse implement for patients with empyema?

encourage deep breathing exercises P: 594

Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)?

it is most contagious during the second week explanation: SARS is most likely to be contagious only when symptoms are present, and patients are most contagious during the second week of illness. Diarrhea and hyperthermia may occur with SARS. Respiratory droplets spread the SARS virus when an infected person coughs or sneezes.

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest?

paradoxical chest movement explanation: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall movement.

Resistance to one of the first-line antituberculotic agents in people who have not had previous treatment is

primary drug resistance. explanation: Primary drug resistance to one of the first-line antituberculotic agents is people who have not had previous treatment

The most diagnostic clinical symptom of pleurisy is:

stabbing pain during respiratory movement

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?

stabbing pain during respiratory movement explanation: When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.